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MHS
101
0518.PR.P.PP 5/18
Agenda:
Program Overview
Claim Process
Claim Dispute Resolution/Appeals
MHS Educational Programs & Services
Provider Demographics/Enrollment Updates
Prior Authorization
Behavioral Health
Envolve Dental
Envolve Vision
Envolve Pharmacy Solutions
Questions
2
Who is MHS?
Managed Health Services (MHS) is a health
insurance provider that has been proudly serving
Indiana residents for over twenty years through
Hoosier Healthwise, the Healthy Indiana Plan (HIP)
and Hoosier Care Connect.
MHS is your choice for better healthcare.
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MHS Products
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Hoosier Healthwise
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What is Hoosier Healthwise?
Hoosier Healthwise is the State of Indiana's health care program for children, pregnant women, and families with low income.Based on family income, children up to age 19 may be eligible for coverage. Hoosier Healthwise covers medical care such as doctor visits, prescription medicine, mental health care, dental care, hospitalizations, surgeries, and family planning at
little or no cost to the member or the member's family.
Goal: To provide healthcare to children and families and to help prevent health problems with early intervention and treatment.
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Who is Eligible for Hoosier
Healthwise?
Hoosier Healthwise covers the following members:
Children up to age 19
The Children's Health Insurance Plan (CHIP):• This option is available for individuals up to age 19 who may earn too much
money to qualify for the standard Hoosier Healthwise coverage.
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Healthy Indiana Plan (HIP)
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What is the Healthy Indiana Plan?
The Healthy Indiana Plan (HIP) is an affordable health insurance program
from the State of Indiana for uninsured adult Hoosiers:
• HIP provides coverage for qualified low-income Hoosiers ages
19 to 64, not receiving Medicare.
• HIP pays for medical expenses and provides incentives for
members to be more health conscious.
*The Healthy Indiana Plan uses a proven, consumer-driven approach
that was pioneered in Indiana.
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Hoosier Care Connect
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Hoosier Care Connect
Overview:
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Hoosier Care Connect is a coordinated care program for Indiana
Health Coverage Programs (IHCP) members age 65 and over, or
with blind or disable who are residing in the community and are not
eligible for Medicare.
Members will select a managed care entity (MCE) responsible
for coordinating care in partnership with their medical
provider(s).
Hoosier Care Connect members will receive all Medicaid-
covered benefits in addition to care coordination services.
• Care coordination services will be individualized based on a
member’s assessed level of need determined through a
health screening.
*Previously or Current children residing in foster care
Claims Process
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Claim Process
Claim Rejection:A rejection is an unclean claim that contains invalid or missing
data elements required for acceptance of the claim in the claim
process system.
*Timely filing is not XXXXXXXXXXXX
Claim Denial:A denial is a claim that has passed edits and is entered into the
system but has been billed with invalid or inappropriate
information causing the claim to deny. An EOP will be sent that
includes the denial reason.
*Timely filing is XXXXXXXXXXXX
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Medical Claim Submission
Electronic Data Interchange Submission:
• Preferred method of claims submission
• Faster and less expensive than paper submission
• MHS Electronic Payor ID 68069
Online through the MHS Secure Provider Portal at
mhsindiana.com:
• Provides immediate confirmation of received claims and acceptance
• Institutional and Professional
• Batch Claims
• Claim Adjustments/Corrections
Paper Claims:
Managed Health Services
PO Box 3002
Farmington, MO 63640-3802
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Claim Submission
Claims must be received within 90 calendar
days of the date of service.
Exceptions (rejections do not substantiate filing
limit requirements):• Newborns (30 days of life or less) – Claims must be received
within 365 days from the date of service. Claim must be filed with
the newborn’s RID #.
• TPL – Claims with primary insurance must be received within 365
days of the date of service with a copy of the primary EOB. If
primary EOB is received after the 365 days, providers have 60
days from date of primary EOB to file claim to MHS. If the third
party does not respond within 90 days, claims may be submitted
to MHS for consideration. Claims submitted must be
accompanied by proof of filing with the patients primary.
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Claim Process
Claim adjustment requests must be submitted within 67
days of the date of the MHS EOP.
*Please note, claims will not be reconsidered after day 67
Resubmissions are accepted:• Electronic adjustments through EDI vendor• Electronic adjustments through the MHS web portal• Hard copy resubmissions:
• May use the Provider Claims Adjustment Request Form
• Must attach EOP, documentation, and explanation of the resubmission reason
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Claim Dispute
Resolution/Appeals
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Dispute Resolution/Appeals
Level One Appeal:
Must be made in writing by using the MHS informal claim dispute/objection form, available at
mhsindiana.com/provider-forms.
Submit all documentation supporting your objection.
Send to MHS within 67 calendar days of receipt of the MHS EOP. Please reference the
original claim number. Requests received after day 67 will not be considered:
Managed Health Services
Attn: Appeals
P.O. Box 3000
Farmington, MO 63640-3800
MHS will acknowledge your appeal within 5 business days.
Provider will receive notice of determination within 45 calendar days of the receipt of the
appeal.
A call to MHS Provider Services does not reserve appeal rights!
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Dispute Resolution/Appeals
Level Two Appeal (Administrative):
If you disagree with your level one decision:
Submit the informal claims dispute or objection form with all supporting
documentation to the MHS appeals address:
Managed Health Services
Attn: Appeals
P.O. Box 3000
Farmington, MO 63640-3800
MHS will acknowledge your appeal within 5 business days.
Provider will receive notice of determination within 45 calendar days of
the receipt of the appeal.
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EFTs and ERAs
MHS uses Payspan Health for:
Web based solution for Electronic Funds
Transfers (EFTs) and Electronic Remittance
Advices (ERAs)
One year retrieval of remittance advice
Provided at no cost to providers and allows
online enrollment
Register at payspanhealth.com:• For questions call 1-877-331-7154 or email
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MHS Educational Programs &
Services
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MHS Educational Programs &
Services:
MHS includes special health incentives and
programs that we make available to our members.
We also offer several programs designed to improve
the health of our members through education and
personal assistance by our professional staff.
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Cent Account Rewards:
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Language Assistance:
Providers should offer language assistance; however, if the office
is unable to assist, MHS can help.
Language assistance is available 24 hours a day, seven days a
week, including holidays and weekends in more than 150
languages.
*Translations for the hearing impaired.
Call MHS Member Services at 1-877-647-4848.
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Transportation:
All MHS Hoosier Healthwise, Hoosier Care Connect,
Healthy Indiana Plan Members qualify for transportation
services provided by LCP.
Rides will take members to and from:
Doctor visits
Medicaid enrollment visits
Pharmacy visits (after a doctor’s visit)
Members need to call MHS Member Services at
1-877-647-4848 to schedule their ride at least
three days before their appointment.
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MHS MemberConnections®
:
This is an outreach team of MHS staff who can help members
one-on-one with understanding their health coverage and other
community resources.
MemberConnections can provide in-person or telephonic help:• Builds relationships with the member and the provider
• Provide members understanding their health benefits and community
resources
• Members in need of transportation, food, shelter, or other health programs,
MemberConnections can help
To find your MemberConnections Representative, please call
1-877-647-4848 and ask for the Representative for your area.
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MHS Member Baby Shower:
Education is key to healthy pregnancies. MHS has created a fun and
informative event to encourage healthy behaviors for our members who
are pregnant or recently delivered.
At the Shower:
Lunch will be provided.
We will stress the importance of scheduling and keeping all prenatal
and post-partum care appointments, as well as, the first year of life
immunization schedule which will include information on:
• OB Case Management services
• Behavioral health services
• Member Benefits like CentAccount, Transportation, NurseWise and
the Health Library
*The members will learn a lot from our community and clinical
partners that present at the shower. Topics such as prenatal and post
partum care, well-child visits, safe sleep, car seat safety,
breastfeeding and more will be discussed.
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MHS Healthy Celebrations:
MHS partners with a PMP office to schedule a specific day and
time for non-compliant MHS members on the PMP’s panel to visit
the office and receive specialty visits and screenings for Children’s
Health: EPSDT/well-child (lead screen age appropriate) and
Women’s Health: Mammography & Chlamydia.
Each member will also receive a goody bag full of MHS and
educational materials and health related giveaways. The family
can also enjoy games, prizes, healthy snacks and refreshments
before they leave the doctor’s office.
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Reliable Cell Phone Programs:
It is important that MHS members can reach their doctors, care
managers and FSSA. That is why MHS offers two programs
that provide access to free cell phones called ConnectionsPlus
and Safelink.
Qualifying members receive 250 free monthly cell minutes as
well as unlimited texting with both programs.
Call MHS Member Services to learn more at 1-877-647-4848.
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MHS 24/7 Nurse Advice Line:
The MHS Nurse Advice Line is available 24 hours a
day, seven days a week to answer members’ health
questions.
The Nurse Advice line staff is bilingual in English
and Spanish.
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Specialized Health Programs:
MHS has several programs designed to help improve the health of its members
through education and personal assistance by our staff including:
Pregnancy
Diabetes
Asthma
COPD
Coronary Artery Disease
Chronic Kidney Disease
Congestive Heart Failure
Lead
Behavioral Health
Depression
Hypertension
ADHD
Autism & Autism Spectrum Disorders
Children with Special Needs Unit
Special Healthcare Needs
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MHS Start Smart for Your Baby
& Special Deliveries:
MHS offers two educational care management programs for MHS members who are pregnant. These programs are called Start Smart for Your Baby and MHS Special Deliveries and are designed to match a pregnant member with an OB Nurse Care Manager.
MHS OB Nurses can:
Help you understand what is happening to your body during the pregnancy.
Talk about problems that may come up during your pregnancy.
Talk about what to do if you have complications during your pregnancy.
Help you make doctor appointments or schedule a free ride to the doctor's office.
Help you get a free cell phone if you need one. You can use this phone to reach your doctor, family and other important people while you are pregnant.
Help you quit smoking or using tobacco.
Help you find more ways to earn CentAccount© rewards by going to your OB doctor visits.
Answer any other questions about your health and the health of your baby.
. 34
First Year of Life Program:
The First Year of Life program matches a member with a Nurse Care
Manager who can answer questions and provide helpful information
sheets to let a member know what to expect as her baby grows.
This Care Management program is designed to encourage education
and compliance with immunizations (shots) and well visits for babies.
Care Managers will also call members and send reminders to schedule
upcoming immunizations and well-child visits with the baby’s doctor as
they are needed.
*To sign up please contact Customer Service
(can be a self referral or a provider referral)
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Children with Special Needs Unit:
Designed to support coordination of care for children with chronic conditions. Children enrolled in the program receive care management services by a dedicated team of MHS doctors, nurses, social workers and care coordinators, specializing in the healthcare needs of children.
This includes conditions such as:
Cerebral palsy
Cystic fibrosis
Developmental disabilities
Autism
Traumatic brain injuries
Congenital syndromes with significant developmental delays
Other special healthcare needs
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MHS Care Coordinator:
All MHS members enrolled in Hoosier Care Connect will be matched with a
MHS Care Coordinator. This Care Coordinator will work with the member to
identify potential barriers or issues related to their health care needs, as well
as, address goals, objectives and interventions to meeting the needs of the
individual.
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Provider Enrollment Updates
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Provider Enrollment:
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Provider Enrollment:
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Provider Enrollment:
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Provider Enrollment:
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Provider Enrollment:
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MHS Behavioral Health
Provider Enrollment:
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Provider Demographic Updates
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Provider Demographic Updates:
Providers can utilize the Demographic Update Tool to update below information.
• Address Changes
• Demographic Changes
• Update Member Assignment Limitations
• Term an Existing Provider
• Make a Change to an IRS Number or NPI Number
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Prior Authorization
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Need to know what requires Authorization:• Reference QRG
• Pre-Authorization tool
How to obtain Authorization:• Online (excluding Home Health and Hospice requests)
• Phone
• Fax
Authorizations do not guarantee payment
Authorization Considerations
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Some services that require prior authorization
regardless of contract status (not inclusive) are:• All elective hospital admissions
• All urgent and emergent hospital admissions (including NICU)
require notice to MHS following the admission.
• Transition to hospice
• Newborn deliveries (Notification Required)
• Rehabilitation facility admissions
• Skilled nursing facility admissions
• Transition of care
• Transplants, including evaluations
Reference QRG for a more detailed listing
Prior Authorization
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Behavioral Health
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Behavioral Health Claim
Submission
Electronic Submission:
• Payer ID 68068
• MHS accepts Third Party Liability (TPL) information via Electronic Data
Interchange
• It is the responsibility of the provider to review the error reports received
from the Clearinghouse (Payer Reject Report)
Online Submission through the MHS Secure Provider Portal:
• Verify Member Eligibility
• Submit and manage both Professional and Facility claims, including 937
batch files
• To create an account, go to: mhsindiana.com
Paper Claims:
• MHS Behavioral Health
PO Box 6800
Farmington, MO 63640-3818
Claim Inquiries:
• Check status online
• Call Provider Services at 1-877-647-4848
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Claim Process
MHS contracted providers have 90 calendar days from date of service to file
a claim.
Non-contracted providers have 365 calendar days from date of service to file
a claim.
When “resubmitting” a corrected claim, you may either send a paper claim
with the words “Resubmission” at the top of the CMS 1500 along with the
original claim number OR you may correct your claim using the Web Portal.
Corrected claims should be resubmitted within 60 calendar days of the date
claim originally paid/denied.
MHS Secure Provider Portal – check claim status or file corrected claims.
EDI transactions accepted through the following vendors:
Trading Partner Payor ID Contact Number
Emdeon 68068 (800) 845-6592
Capario 68068 (800) 792-5256, x812
Availity 68068 (800) 282-4548
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Claims Dispute Resolution
Must be made in writing by using the MHS Behavioral Health Informal Claim
Dispute or objection form, available at mhsindiana.com/provider-forms.
Submit all documentation supporting your objection.
Send to MHS within 67 calendar days of receipt of the MHS EOP. Please
reference the original claim number. Requests received after day 67 will not be
considered:MHS Behavioral Health Services
Attn: Appeals Department
P.O. Box 6000
Farmington, MO 63640-3809
MHS will make all reasonable efforts to review your documentation and respond
to you within 30 calendar days.
If you do not receive a response within 30 calendar days, consider the original
decision to have been upheld.
At that time (or upon receipt of our response if sooner), you will have up to 67
calendar days from date on Explanation of Payment (EOP) to initiate a formal
claim appeal.
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Prior Authorization
Prior Authorization:
• Please call MHS Care Management for inpatient and partial hospitalization
authorizations at 1-877-647-4848. Follow prompts to Behavioral Health.
• Authorization forms may be obtained on our website:
• Outpatient Treatment Request (OTR) Form/Tip-Sheet/Training
• Intensive Outpatient/Day Treatment Form Mental Health/Chemical
Dependency
• Applied Behavioral Analysis Treatment (OTR)
• Psychological Testing Authorization Request Form (Outpatient & Inpatient)
Medical Necessity Appeals:
• Submit to:
MHS
Attn: Appeals Coordinator
12515-8 Research Blvd., Suite 400
Austin, TX 78707
• Or Fax to: 1-866-714-7991
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Prior Authorization
Facility Services:
Inpatient Admissions
Intensive Outpatient Program (IOP)
Partial Hospitalization
SUD Residential Treatment
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Prior Authorization
Professional Services:
Psychiatric Diagnostic Evaluation (Limited to 1 per member per
12 month rolling year without authorization)
Electroconvulsive Therapy
Psychological TestingUnless for Autism: then no auth is required
Developmental Testing, with interpretation and report (non-
EPSDT)
Neurobehavioral status exam, with interpretation and report
Neuropsych Testing per hour, face to face Unless for Autism: then no auth is required
Non-Participating Providers only
ABA Services
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Envolve Dental
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Envolve Dental:
All dental paper claims should be billed to:
Envolve Dental Claims:IN
P.O. Box 20847
Tampa, FL 33622-0847
For questions please contact:• Envolve Dental Provider Services at 1-855-609-5157
• Candy Ervin, Envolve Dental Indiana Provider
Relations Specialist Market Manager, at
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Envolve Dental:
Envolve Dental clearinghouse payer ID – 46278
Web address: envolvedental.com
Provider Web Portal Address: pwp.envolvedental.com
Contracting Paperless - Go to our secure website at
providers.envolvedental.com
Credentialing Paperless –
[email protected]• Entire process typically is completed within 45 days
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Envolve Vision
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Envolve Vision:
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Envolve Pharmacy Solutions
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Envolve Pharmacy Solutions:
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Provider Network Territories:
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MHS Provider Relations Team:
Candace ErvinEnvolve Dental Indiana Provider
Relations 1-877-647-4848 ext. 20187
Candace.Ervin@envolvehealth.
com
Chad Pratt Provider Relations Specialist –
Northeast Region1-877-647-4848 ext. 20454 [email protected]
Tawanna DanzieProvider Relations Specialist –
Northwest Region1-877-647-4848 ext. 20022 [email protected]
Jennifer GarnerProvider Relations Specialist –
Southeast Region1-877-647-4848 ext. 20149 [email protected]
Taneya Wagaman Provider Relations Specialist –
Central Region1-877-647-4848 ext. 20202 [email protected]
Katherine Gibson Provider Relations Specialist –
North Central Region1-877-647-4848 ext. 20959 [email protected]
Esther CervantesProvider Relations Specialist –
South West Region1-877-647-4848 ext. 20947
Estherling.A.PimentelCervantes
@mhsindiana.com
LaKisha BrowderBehavioral Health Provider
Relations Specialist - East Region1-877-647-4848 ext. 20224
lakisha.j.browder@mhsindiana.
com
Recap Of What You Learned:
Overview of Hoosier Healthwise, Hoosier Care
Connect and Healthy Indiana Plan
Claim Dispute Resolution/Appeals
MHS Educational Programs & Services Offer
How to submit provider enrollments and
updates
How to use the Prior Authorization tool
MHS Behavioral Health
Envolve Specialty Companies
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Questions?
Thank you for being our partner in care.